1
|
AlFaris NA, Alshwaiyat NM, ALTamimi JZ, Alagal RI, AlSalehi SM, Al Zarah RI, Alfaiz RF, Alhariqi AI, Alshamri DF, AlSouan NA, AlMousa LA. Nutritional Status and Dietary Behaviors of Children with Intellectual or Developmental Disabilities in Saudi Arabia: A Systematic Review. J Multidiscip Healthc 2024; 17:3371-3399. [PMID: 39045491 PMCID: PMC11264128 DOI: 10.2147/jmdh.s473107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 06/27/2024] [Indexed: 07/25/2024] Open
Abstract
Children with intellectual or developmental disabilities are susceptible to malnutrition. This systematic review was conducted to assess the nutritional status and dietary behaviors of children with intellectual or developmental disabilities in Saudi Arabia. The target population was children from Saudi Arabia aged 18 years or younger and diagnosed with intellectual or developmental disabilities. Appropriate research studies that were published from inception up to December 2023 were obtained and reviewed. The outcomes of interest, including anthropometric data, laboratory data, dietary intake data, and dietary behaviors data, were collected and organized in relevant tables. The methodological quality and bias risk for the involved studies were evaluated. Out of 286 screened articles, 31 research articles were selected. The review results show that the rates of overweight and obesity were significantly higher among children with intellectual or developmental disabilities compared to typically developing children. The laboratory data revealed that they were more likely to have nutritional deficiencies. Low intake of energy, protein, and several micronutrients is frequently reported among them. Moreover, they are anticipated to have unhealthy dietary behavior. In conclusion, the findings suggested that children with intellectual or developmental disabilities were at higher risk of malnutrition including deploying obesity and nutritional deficiencies. Healthy and balanced nutrition that considers dietary requirements and food preferences is critical to maintaining the optimal development of these children. This review could invite researchers and policy-makers in Saudi Arabia to put more effort into integrating individuals with disability into the healthcare system and community. Further research is required to determine the types of intervention measures that can be taken to reduce the risk of malnutrition. Additional action is needed to monitor the implementation of national policies and programs that target this part of society.
Collapse
Affiliation(s)
- Nora A AlFaris
- Department of Physical Sports Sciences, College of Sports Sciences & Physical Activity, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Naseem M Alshwaiyat
- Department of Nutrition and Food Technology, Faculty of Agriculture, Jordan University of Science and Technology, Irbid, Jordan
| | - Jozaa Z ALTamimi
- Department of Physical Sports Sciences, College of Sports Sciences & Physical Activity, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Reham I Alagal
- Department of Health Sciences, College of Health and Rehabilitation Sciences, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Saleh M AlSalehi
- Child Development Center, King Abdullah Bin Abdulaziz University Hospital (KAAUH), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Raed I Al Zarah
- Department of Pediatrics, King Abdullah bin Abdulaziz University Hospital (KAAUH), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Razan F Alfaiz
- Department of Pediatrics, King Abdullah bin Abdulaziz University Hospital (KAAUH), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Ameera I Alhariqi
- Department of Pediatrics, King Abdullah bin Abdulaziz University Hospital (KAAUH), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Dalal F Alshamri
- Department of Clinical Nutrition, King Abdullah Bin Abdulaziz University Hospital (KAAUH), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Noura A AlSouan
- Department of Clinical Nutrition, King Abdullah Bin Abdulaziz University Hospital (KAAUH), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Lujain A AlMousa
- Department of Health Sciences, College of Health and Rehabilitation Sciences, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| |
Collapse
|
2
|
Rice I, Opondo C, Nyesigomwe L, Ekude D, Magezi J, Kalanzi A, Kerac M, Hayes J, Robello M, Halfman S, DeLacey E. Children with disabilities lack access to nutrition, health and WASH services: A secondary data analysis. MATERNAL & CHILD NUTRITION 2024; 20:e13642. [PMID: 38563355 PMCID: PMC11168356 DOI: 10.1111/mcn.13642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 04/04/2024]
Abstract
Malnutrition and disability are major global public health problems. Poor diets, inadequate access to nutrition/health services (NaHS), and poor water, sanitation and hygiene (WASH) all increase the risk of malnutrition and infection. This leads to poor health outcomes, including disability. To better understand the relationship between these factors, we explored access to NaHS and household WASH and dietary adequacy among households with and without children with disabilities in Uganda. We used cross-sectional secondary data from 2021. Adjusted logistic regression was used to explore associations between disabilities, access to NaHS, WASH and dietary adequacy. Of the 6924 households, 4019 (57.9%) reported having access to necessary NaHS, with deworming and vaccination reported as both the most important and most difficult to access services. Access to services was lower for households with children with disabilities compared to those without, after adjusting for likely confounding factors (Odds ratio = 0.70; 95% CI 0.55-0.89, p = 0.003). There is evidence of an interaction between disability and WASH adequacy, with improved WASH adequacy associated with improved access to services, including for children with disabilities (interaction odds ratio = 1.12, 95% CI: 1.02-1.22, p = 0.012). The proportion of malnourished children was higher among households with children with disabilities than households without it (6.3% vs. 2.4% p < 0.001). There are concerning gaps in access to NaHS services in Uganda, with households with children with disabilities reporting worse access, particularly for those with low WASH adequacy. Improved and inclusive access to NaHS and WASH needs to be urgently prioritized, especially for children with disabilities.
Collapse
Affiliation(s)
- Isabel Rice
- Department of Population Health, London School of Hygiene & Tropical Medicine, Faculty of Epidemiology and Population HealthUniversity of LondonLondonUK
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, Faculty of Epidemiology and Population HealthUniversity of LondonLondonUK
| | | | | | | | | | - Marko Kerac
- Department of Population Health, London School of Hygiene & Tropical Medicine, Faculty of Epidemiology and Population HealthUniversity of LondonLondonUK
- London School of Hygiene & Tropical Medicine, Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH)University of LondonLondonUK
| | | | | | | | - Emily DeLacey
- Department of Population Health, London School of Hygiene & Tropical Medicine, Faculty of Epidemiology and Population HealthUniversity of LondonLondonUK
- London School of Hygiene & Tropical Medicine, Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH)University of LondonLondonUK
- Holt InternationalEugeneOregonUSA
| |
Collapse
|
3
|
Alam MB, Khanam SJ, Rana MS, Khandaker G, Kabir MA, Khan MN. Effects of disability on adverse health outcomes and anthropometric deficits among under-five children in South Asian countries: evidence from multiple indicator cluster surveys. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 25:100401. [PMID: 38616818 PMCID: PMC11015120 DOI: 10.1016/j.lansea.2024.100401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 03/06/2024] [Accepted: 03/25/2024] [Indexed: 04/16/2024]
Abstract
Background Children with disabilities face an increased risk of adverse health outcomes and poor anthropometric deficits, although the focus on them is limited in the South Asian context thus far and need newer and more evidence. This study investigates the effects of disability on adverse health outcomes and anthropometric deficits among 2-4 years aged children in South Asian countries. Methods We analyzed data from 93,180 children aged 2-4 years across Bangladesh, Nepal, Pakistan, and Afghanistan using Multiple Indicator Cluster Surveys (2017-2023). Disability status was the primary exposure, and outcomes included adverse health outcome (acute respiratory infection, diarrhea, fever), anthropometric deficit (stunting, wasting, underweight), and healthcare service sources during adverse health events (care received from skilled healthcare personnel, care received from non-professional personnel, and care received from health facility workers other than skilled healthcare personnel). Using multilevel and multinomial logistic regression models, we examined associations between exposure and outcome variables, adjusting for covariates. Findings We found average disability prevalence in South Asia was 8.7% (8.3-9.0; n = 8072), varying from 3.4% (3.0-3.8; n = 446) in Bangladesh to 12.3% (11.4-13.3; n = 1259) in Afghanistan. Common health issues included fever (n = 24,982, 26.8%, 26.2-27.4) and diarrhea (n = 14,081, 15.1%, 14.7-15.6), while prevalent poor anthropometric deficits were stunting (n = 39,766, 42.7%, 42.0-43.3) and underweight (n = 22,390, 24.0%, 23.5-24.5). Children with disability had 1.30 (95% CI: 1.21-1.40) to 1.60 (95% CI: 1.47-1.75) times and 1.17 (95% CI: 1.05-1.29) to 1.39 (95% CI: 1.30-1.48) times higher likelihoods of adverse health outcomes and anthropometric deficits, respectively, with variations observed among countries and different disability types. Individuals with disability were 1.16 (95% CI: 1.00-1.35) to 1.26 (95% CI: 1.01-1.58) times more likely to receive healthcare services from skilled healthcare personnel compared to health facility workers other than skilled healthcare personnel. Interpretation This study findings emphasizes the need for community-level awareness programs to improve anthropometric well-being and healthcare of the children with disability. Funding This research did not receive any specific funds.
Collapse
Affiliation(s)
- Md Badsha Alam
- Department of Population Science, Jatiya Kabi Kazi Nazrul Islam University, Trishal, Mymensingh, Bangladesh
| | - Shimlin Jahan Khanam
- Department of Population Science, Jatiya Kabi Kazi Nazrul Islam University, Trishal, Mymensingh, Bangladesh
| | - Md Shohel Rana
- Department of Population Science, Jatiya Kabi Kazi Nazrul Islam University, Trishal, Mymensingh, Bangladesh
| | - Gulam Khandaker
- Central Queensland Public Health Unit, Central Queensland Hospital and Health Service, Rockhampton, Australia
- School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, Australia
| | - Md Awal Kabir
- Department of Social Work, Pabna University of Science and Technology, Pabna, Bangladesh
| | - Md Nuruzzaman Khan
- Department of Population Science, Jatiya Kabi Kazi Nazrul Islam University, Trishal, Mymensingh, Bangladesh
| |
Collapse
|
4
|
Mathabela B, Madiba S, Modjadji P. Exploring Barriers to Accessing Sexual and Reproductive Health Services among Adolescents and Young People with Physical Disabilities in South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:199. [PMID: 38397689 PMCID: PMC10887722 DOI: 10.3390/ijerph21020199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024]
Abstract
Despite South Africa having a progressive and liberal sexual and reproductive health (SRH) policy framework, adolescents and young people with disabilities (AYPWDs) are less likely to receive sexual and reproductive healthcare, being consequently predisposed to a long-term detrimental impact on their health. Our study explored the barriers to accessing sexual and reproductive health services (SRHSs) in clinics among AYPWDs in Mpumalanga, South Africa. We conducted a descriptive qualitative study with twenty-seven AYPWDs in four focus group discussions using semi-structured interviews, audiotaped and transcribed verbatim, and then applied a thematic analysis of the data. Employing a socio-ecological model, the findings show a poor socioeconomic status, lack of information on SRH, and the attitudes of AYPWDs as barriers at the individual level, hindering AYPWDs from accessing SRHSs in clinics. AYPWDs also faced difficulties to talk about SRH with parents, a lack of support to seek SRHSs, improper care from family/parents, and negative attitudes of friends, at the interpersonal level. They further expressed barriers at the community/societal level as negative attitudes of non-disabled community members and poor infrastructure for wheelchair use. At the organization level, their access to SRHSs was negatively affected by HCWs' maltreatment, described in the forms of negative attitudes, being judgmental using verbal abuse, discrimination, and bullying. Furthermore, AYPWDs described difficulties in communication with HCWs, as well as violating their confidentiality and misconceived ideas on their sexuality. Intensified efforts to strengthen public health strategies are needed to improve access to SRHSs by AYPWDs in South Africa, as well as enhancing the proficiency and communication skills of HCWs and educating AYPWDs, parents, and non-disabled community members on SRH.
Collapse
Affiliation(s)
- Bheki Mathabela
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria 0208, South Africa;
| | - Sphiwe Madiba
- Faculty of Health Sciences, University of Limpopo, Polokwane 0700, South Africa;
| | - Perpetua Modjadji
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria 0208, South Africa;
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town 7505, South Africa
- Department of Life and Consumer Sciences, College of Agriculture and Environmental Sciences, University of South Africa, Johannesburg 1709, South Africa
| |
Collapse
|
5
|
Opoku MP, Anwahi N, Belbase S, Shah H, Alkateri T, Moustafa A. Accessibility of nutritional services for children with autism spectrum disorder in the United Arab Emirates: Insights from special education teachers and parents. RESEARCH IN DEVELOPMENTAL DISABILITIES 2023; 138:104521. [PMID: 37148575 DOI: 10.1016/j.ridd.2023.104521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 04/08/2023] [Accepted: 04/30/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Goal 2 of United Nation's Sustainable Development Goals exhorts countries to provide guidelines on better nutrition for all children. In response, the United Arab Emirates (UAE) government designed a national nutrition framework to encourage better eating habits. However, large body of literature has reported that children with ASD are at high risks of malnutrition and poor eating habits. Yet, in the UAE and other contexts, there is limited research on accessibility of nutritional services to adults in the lives of children with ASD. AIMS As parents and teachers spend the most time with children with ASD, this study sought to understand their perceptions of the availability of nutritional services for such children in the UAE. METHOD AND PROCEDURES Penchansky and Thomas' (1981) health access theory served as the theoretical framework; its five tenets (geography, finance, accommodation, resources and acceptability) informed the design of a semi-structured interview guide. Data were collected from 21 participants, comprising 6 parents and 15 teachers of children with ASD. OUTCOMES AND RESULTS Thematic analysis revealed that participants perceived accommodation, acceptability, and human resource availability as barriers to accessibility. However, geographical and financial accessibility were not identified as challenges. CONCLUSIONS AND IMPLICATIONS The study calls for health policymakers to formalise nutritional services as an integrated part of the UAE health system, while also extending services to children with ASD. CONTRIBUTION This study makes a substantial contribution to the literature. First, it addresses the needs for nutritional services for children with ASD. There is a limited body of knowledge on whether children with ASD have access to the requisite nutrition for development This study sheds light on an area that has received limited scholarly insight. Second, it adds to the usage of health access theory in studies on nutritional services for children with ASD.
Collapse
Affiliation(s)
- Maxwell Peprah Opoku
- Special Education Department, United Arab Emirates University, Al-Ain, United Arab Emirates.
| | - Noora Anwahi
- Special Education Department, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Shashidhar Belbase
- Curriculum and Method of Instruction, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Haseena Shah
- Special Education Department, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Thara Alkateri
- Special Education Department, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Ashraf Moustafa
- Special Education Department, United Arab Emirates University, Al-Ain, United Arab Emirates
| |
Collapse
|
6
|
Sapkota KP, Shibanuma A, Ong KIC, Kiriya J, Jimba M. Accommodation and disability-specific differences in nutritional status of children with disabilities in Kathmandu, Nepal: A cross-sectional study. BMC Public Health 2023; 23:315. [PMID: 36782145 PMCID: PMC9926754 DOI: 10.1186/s12889-023-14999-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 01/05/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Worldwide, more than 150 million children < 18 years live with disabilities. These children are more vulnerable to malnutrition regardless of institutional care that they receive, such as daycare or residential care. In Nepal, little is known about the status of malnutrition and factors associated with malnutrition among children with disabilities. This study was conducted to investigate the factors associated with malnutrition based on the types of disability and accommodation. METHODS This institution-based, cross-sectional study was conducted in 22 institutions in the Kathmandu Valley, Nepal. From these institutions, parents/guardians of all children with disabilities were recruited who were present there on the day of data collection. They were interviewed using a structured questionnaire. The questionnaire included questions on demographic characteristics, disability type and severity, accommodation place, feeding practices, and dietary patterns. The outcome variables, stunting, underweight, and obesity were measured using height-for-age, weight-for-age, and body mass index-for-age, respectively. A generalized linear model was used to investigate the factors associated with stunting and underweight, and multinomial logistic regression was used to identify the factors associated with overweight and obesity. RESULTS Among the 345 children with disabilities, 45% were stunted, 33% were underweight, 19% were thin, and 12% were overweight. Children with physical disabilities (relative risk ratio = 1.88, 95% confidence interval [CI] = 1.26-2.81) were more likely to be stunted than those with sensory disabilities. Children with autism (adjusted odds ratio [aOR] = 5.56, 95% CI: 1.23-25.23) and intellectual disabilities (aOR = 5.84, 95% CI: 1.59-21.51) were more likely to be overweight and obese than those with sensory disabilities. No evidence was found regarding an association between accommodation type and malnutrition. CONCLUSION Children with disabilities are vulnerable to malnutrition in several ways. Different types of disabilities are associated with different forms of malnutrition. Considering the types of disabilities, tailor-made approaches should be adopted to improve malnutrition status.
Collapse
Affiliation(s)
- Krishna Prasad Sapkota
- grid.26999.3d0000 0001 2151 536XDepartment of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Shibanuma
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Ken Ing Cherng Ong
- grid.26999.3d0000 0001 2151 536XDepartment of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junko Kiriya
- grid.26999.3d0000 0001 2151 536XDepartment of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masamine Jimba
- grid.26999.3d0000 0001 2151 536XDepartment of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
7
|
Engl M, Binns P, Trehan I, Lelijveld N, Angood C, McGrath M, Groce N, Kerac M. Children living with disabilities are neglected in severe malnutrition protocols: a guideline review. Arch Dis Child 2022; 107:637-643. [PMID: 35121609 DOI: 10.1136/archdischild-2021-323303] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/19/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE Children living with disabilities are at high risk of malnutrition but have long been marginalised in malnutrition treatment programmes and research. The 2013 WHO guidelines for severe acute malnutrition (SAM) mention disability but do not contain specific details for treatment or support. This study assesses inclusion of children living with disabilities in national and international SAM guidelines. METHODS National and international SAM guidelines available in English, French, Spanish or Portuguese were sourced online and via direct enquiries. Regional guidelines or protocols subspecialising in a certain patient group (eg, people living with HIV) were excluded. Eight scoping key informant interviews were conducted with experts involved in guideline development to help understand possible barriers to formalising malnutrition guidance for children living with disabilities. RESULTS 71 malnutrition guidelines were reviewed (63 national, 8 international). National guidelines obtained covered the greater part of countries with a high burden of malnutrition. 85% of guidelines (60/71) mention disability, although mostly briefly. Only 4% (3/71) had a specific section for children living with disabilities, while the remaining lacked guidance on consistently including them in programmes or practice. Only one guideline mentioned strategies to include children living with disabilities during a nutritional emergency. Most (99%,70/71) did not link to other disability-specific guidelines. Of the guidelines that included children living with disabilities, most only discussed disability in general terms despite the fact that different interventions are often needed for children with different conditions. Interviews pointed towards barriers related to medical complexity, resource constraints, epidemiology (eg, unrecognised burden), lack of evidence and difficulty of integration into existing guidelines. CONCLUSION Children living with disabilities are under-recognised in most SAM guidelines. Where they are recognised, recommendations are very limited. Better evidence is urgently needed to identify and manage children living with disabilities in malnutrition programmes. More inclusion in the 2022 update of the WHO malnutrition guidelines could support this vulnerable group.
Collapse
Affiliation(s)
- Magdalena Engl
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Indi Trehan
- Departments of Pediatrics, Global Health, and Epidemiology, University of Washington, Seattle, Washington, USA
| | | | | | | | - Nora Groce
- International Disability Research Centre, Department of Epidemiology and Health Care, University College London, London, UK
| | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
8
|
DeLacey E, Hilberg E, Allen E, Quiring M, Tann CJ, Groce NE, Vilus J, Bergman E, Demasu-Ay M, Dam HT, Kerac M. Nutritional status of children living within institution-based care: a retrospective analysis with funnel plots and control charts for programme monitoring. BMJ Open 2021. [PMCID: PMC8719208 DOI: 10.1136/bmjopen-2021-050371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objectives The aim of this study is to fill a key information gap on the nutrition-related epidemiology of orphaned and vulnerable children living within institution-based care (IBC) across six countries. Design A retrospective analysis with Shewhart control charts and funnel plots to explore intersite and over time variations in nutritional status. Setting We conducted a retrospective analysis of records from Holt International’s Child Nutrition Programme from 35 sites in six countries; Mongolia, India, Ethiopia, Vietnam, China and the Philippines. Participants Deidentified health records from Holt International’s online nutrition screening database included records from 2926 children, 0–18 years old. Data were collected from 2013 to 2020 and included demographic and health information. Results At initial screening, 717 (28.7%) children were anaemic, 788 (34.1%) underweight, 1048 (37.3%) stunted, 212 (12.6%) wasted, 135 (12%) overweight or obese and 339 (31%) had small head circumference. Many had underlying conditions: low birth weight, 514 (57.5%); prematurity, 294 (42.2%) and disabilities, 739 (25.3%). Children with disabilities had higher prevalence of malnutrition compared with counterparts without disabilities at baseline and 1-year screenings. There was marked intersite variation. Funnel plots highlight sites with malnutrition prevalence outside expected limits for this specific population taking into consideration natural variation at baseline and at 1 year. Control charts show changes in site mean z-scores over time in relation to site control limits. Conclusions Malnutrition is prevalent among children living within IBC, notably different forms of undernutrition (stunting, underweight, wasting). Underlying risk factors are also common: prematurity, low birth weight and disability. Nutrition interventions should take into account the needs of this vulnerable population, especially for infants and those with disabilities. Using control charts to present data could be especially useful to programme managers as sites outside control limits could represent: problems to be investigated; good practices to be shared.
Collapse
Affiliation(s)
- Emily DeLacey
- Department of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Nutrition & Health Department, Holt International, Eugene, Oregon, USA
- Centre for Maternal Adolescent Reproductive and Child Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Evan Hilberg
- Nutrition & Health Department, Holt International, Eugene, Oregon, USA
| | - Elizabeth Allen
- Department of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Michael Quiring
- Nutrition & Health Department, Holt International, Eugene, Oregon, USA
| | - Cally J Tann
- Centre for Maternal Adolescent Reproductive and Child Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Neonatal Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Nora Ellen Groce
- International Disability Research Centre, University College London, London, UK
| | - James Vilus
- Holt Haiti Country Office, Holt International, Port-au-Prince, Haiti
| | - Ethan Bergman
- Department of Health Sciences, Central Washington University, Ellensburg, Washington, USA
| | - Merzel Demasu-Ay
- Nutrition Department, Kaisahang Buhay Foundation, Inc, Quezon City, Philippines
| | - Hang T Dam
- Nutrition & Health Department, Holt International, Eugene, Oregon, USA
| | - Marko Kerac
- Department of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Centre for Maternal Adolescent Reproductive and Child Health, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
9
|
Fentanew M, Yitayal MM, Chala KN, Kassa T. Magnitude of Satisfaction and Associated Factors Among Caregivers of Children with Disabilities Towards Community-Based Rehabilitation Service in Central and North Gondar Zone, Northwest Ethiopia: A Community-Based Cross-Sectional Study. J Multidiscip Healthc 2021; 14:2565-2575. [PMID: 34556991 PMCID: PMC8453174 DOI: 10.2147/jmdh.s325737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/03/2021] [Indexed: 12/14/2022] Open
Abstract
Introduction Community-based rehabilitation service (CBR) is a community development strategy set for persons with disabilities and their families. Measuring caregivers’ satisfaction is a recommended approach to know the overall satisfaction of rehabilitation service. Therefore, this study aimed to assess the magnitude of satisfaction and associated factors among caregivers of children with disabilities towards community-based rehabilitation in Central and North Gondar zone, North West Ethiopia. Methods A community-based cross-sectional study was conducted from March to September 2020. The data were collected by socio-demographic variables, types of services, types of disabilities, and Client Satisfaction Questionnaire (CSQ-8). Data analysis was done by SPSS Version-20 statistical software. Descriptive statistics, bi-variable, and multivariable logistic regression analysis were computed. The multivariable logistic regression analysis model a P-value <0.05 was used to identify the associated factors with caregivers’ satisfaction. Results The study showed that the overall caregivers’ satisfaction with community-based rehabilitation service among caregivers of children with disabilities was 60.9% (95% CI; 55–66%). Female gender (AOR: 0.19, 95% CI: 0.05–0.68), older age (AOR: 0.160, 95% CI: 0.03–0.85), being farmer (AOR: 0.14, 95% CI: 0.05–0.42), North Gondar zone residence (AOR: 7.02, 95% CI: 6.78–8.59), high monthly income (AOR: 2.48, 95% CI: 1.09–5.61), got two or more type of service (AOR: 3.65, 95% CI: 2.64–12.39), service duration 8–14 years (AOR: 4.36, 95% CI: 1.44–7.04) and service frequency 5–8 times per month (AOR: 3.91, 95% CI 2.18–7.01) were factors associated with the caregivers’ satisfaction on community based-rehabilitation service. Conclusion and Recommendation The magnitude of caregivers’ satisfaction with community-based rehabilitation services in the study area was more than half. Female gender, older age, being farmer, high monthly income, North Gondar zone residence, the high number of services, duration of services started and frequency of follow-up were factors significantly associated with caregiver’s satisfaction.
Collapse
Affiliation(s)
- Molla Fentanew
- Department of Physiotherapy, School of Medicine, College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Melisew Mekie Yitayal
- Department of Physiotherapy, School of Medicine, College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Kalkidan Nigussie Chala
- Department of Physiotherapy, School of Medicine, College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Tesfa Kassa
- Department of Physiotherapy, School of Medicine, College of Medicine and Health Sciences, Gondar, Ethiopia
| |
Collapse
|
10
|
Harris CM, Wright SM. Malnutrition in Hospitalized Adults With Cerebral Palsy. JPEN J Parenter Enteral Nutr 2021; 45:1749-1754. [PMID: 33438229 DOI: 10.1002/jpen.2067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/14/2020] [Accepted: 01/05/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Malnutrition among hospitalized adults with cerebral palsy (CP) has not been extensively explored. We sought to identify impacts of malnutrition on clinical and resource outcomes among hospitalized adults with CP. METHODS This retrospective cohort study surveyed years 2016 and 2017 from the National Inpatient Sample database. Regression models evaluated mortality and resource utilization. RESULTS 154,219 adults with CP were hospitalized. Among them, 21,064/154,219 (13.5%) had malnutrition. Patients with and without malnutrition were similar in age (mean age ± SEM, 45.1 ± 0.30 vs 45.2 ± 0.18 years; P = .70). Patients with malnutrition were more likely male (12,175/21,604 [57.8%] vs 72,929/133,155 [54.8%], P < .01) and had higher comorbidity scores (Charlson comorbidity score ≥ 3; 2,464/21,064 [11.7%] vs 14,380/133,155 [10.8%]; P = .01). Mortality rates were higher among patients with malnutrition (905/21,064 [4.3%] vs 2,796/21,064 [2.1%], P < .01), and they had higher odds for mortality (adjusted odds ratio [aOR] = 2.1; CI, 1.7-2.5; P < .01). Those with malnutrition were less likely discharged home (aOR = 0.52; CI, 0.48-0.56; P < .01). Hospital charges were higher (adjusted mean difference [aMD] = +$42,540; CI, $36,934-48,146; P < .01) and length of stay longer (aMD = +4.3 days; CI, 3.9-4.7; P < .01) among patients with malnutrition. CONCLUSION Malnutrition in hospitalized patients with CP is associated with increased mortality and hospital resource utilization. Flagging these patients as being "high risk" when they are hospitalized may result in heightened attentiveness about clinical outcomes in this vulnerable population.
Collapse
Affiliation(s)
- Ché Matthew Harris
- Department of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Scott Mitchell Wright
- Department of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| |
Collapse
|
11
|
Lelijveld N, Groce N, Patel S, Nnensa T, Chimwezi E, Gladstone M, Mallewa M, Wells J, Seal A, Kerac M. Long-term outcomes for children with disability and severe acute malnutrition in Malawi. BMJ Glob Health 2020; 5:bmjgh-2020-002613. [PMID: 33028697 PMCID: PMC7542612 DOI: 10.1136/bmjgh-2020-002613] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/26/2020] [Accepted: 08/28/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Severe acute malnutrition (SAM) and disability are major global health issues. Although they can cause and influence each other, data on their co-existence are sparse. We aimed to describe the prevalence and patterns of disability among a cohort of children with SAM. Methods A longitudinal cohort study in Malawi followed SAM survivors up to 7 years postdischarge. Clinical and anthropometric profiles were compared with sibling and community controls. Disability at original admission was identified clinically; at 7-year follow-up a standardised screening tool called ‘the Washington Group Questionnaire’ was used. Results 60/938 (6.4%) of admissions to SAM treatment had clinically obvious disability at admission. Post-treatment mortality was high, with only 11/60 (18%) surviving till 7-year follow-up. SAM children with a disability at admission had 6.99 (95% CI 3.49 to 14.02; p<0.001) greater risk of dying compared with children without disability. They were also older, less likely to be HIV positive or have oedema and more severely malnourished. Long-term survivors were more stunted, had less catch-up growth, smaller head circumference, weaker hand grip strength and poorer school achievement than non-disabled survivors. The Washington Group Questionnaire confirmed disability in all who had been identified clinically, and identified many who had not been previously flagged. Conclusion Disability is common among children affected by SAM. Those with disability-associated SAM have greatly increased risk of dying even if they survive the initial episode of malnutrition. Survivors have poorer growth, physical strength and school achievement. To enable all children to survive and thrive post-SAM, it is vital to focus more on those with disabilities. SAM treatment programmes should consider using not just clinical assessment but structured assessments to better identify at-risk individuals as well as understand the population of children for which they are developing services.
Collapse
Affiliation(s)
- Natasha Lelijveld
- Institute for Global Health, University College London, London, UK .,Clinical Research Programme, Malawi-Liverpool Wellcome Trust, Blantyre, Malawi
| | - Nora Groce
- Department of Epidemiology and Health Care, UCL International Disability Research Centre, London, UK
| | - Seema Patel
- Department of Epidemiology and Health Care, UCL International Disability Research Centre, London, UK
| | - Theresa Nnensa
- Clinical Research Programme, Malawi-Liverpool Wellcome Trust, Blantyre, Malawi
| | - Emmanuel Chimwezi
- Clinical Research Programme, Malawi-Liverpool Wellcome Trust, Blantyre, Malawi
| | - Melissa Gladstone
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Macpherson Mallewa
- Department of Paediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Southern Region, Malawi
| | - Jonathan Wells
- Childhood Nutrition Research Centre, Institute of Child Health, University, London, UK
| | - Andrew Seal
- Institute for Global Health, University College London, London, UK
| | - Marko Kerac
- Clinical Research Programme, Malawi-Liverpool Wellcome Trust, Blantyre, Malawi.,Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
12
|
Lusambili A, Naanyu V, Manda G, Mossman L, Wisofschi S, Pell R, Jadavji S, Obure J, Temmerman M. Nutritional Influences on the Health of Women and Children in Cabo Delgado, Mozambique: A Qualitative Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176205. [PMID: 32867019 PMCID: PMC7503663 DOI: 10.3390/ijerph17176205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/31/2020] [Accepted: 08/13/2020] [Indexed: 11/16/2022]
Abstract
In 2017, the Government of Mozambique declared localized acute malnutrition crises in a range of districts across Mozambique including Cabo Delgado. This is in spite of intensive efforts by different non-governmental organizations (NGO) and the Government of Mozambique to expand access to information on good nutritional practices as well as promote nutrition-specific interventions, such as cooking demonstrations, home gardens and the distribution of micronutrient powder to children. This paper examines and discusses key nutritional influences on the health of pregnant and breastfeeding mothers in Cabo Delgado province, Mozambique. We conducted 21 key informant interviews (KIIs) with a wide range of stakeholders and 16 in-depth interviews (IDIs) with women. In addition, we conducted four focus group discussions with each of the following groups: (1) pregnant adolescent girls, (2) pregnant women >20 yrs, (3) women >20 yrs with babies <6 mths who were not practicing exclusive breastfeeding, (4) women >20 yrs of children <2 yrs and (5) with fathers of children <2 yrs. Data were analyzed thematically using NVIVO software. There is no single widely held influence on pregnant and breast-feeding women’s nutritional decision-making, choices and food consumption. Rather, variables such as social-cultural, environmental, economic, gender, knowledge and information intersect in their roles in nutritional food choices.
Collapse
Affiliation(s)
- Adelaide Lusambili
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi P.O. Box 30270-00100, Kenya; (V.N.); (S.W.); (J.O.); (M.T.)
- Department of Population Health, Aga Khan University, Nairobi P.O. Box 30270-00100, Kenya
- Correspondence:
| | - Violet Naanyu
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi P.O. Box 30270-00100, Kenya; (V.N.); (S.W.); (J.O.); (M.T.)
| | - Gibson Manda
- Aga Khan Foundation Mozambique, Maputo P.O. Box 746, Mozambique;
| | - Lindsay Mossman
- Aga Khan Foundation, Ottawa, ON K1N 1K6, Canada; (L.M.); (R.P.); (S.J.)
| | - Stefania Wisofschi
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi P.O. Box 30270-00100, Kenya; (V.N.); (S.W.); (J.O.); (M.T.)
| | - Rachel Pell
- Aga Khan Foundation, Ottawa, ON K1N 1K6, Canada; (L.M.); (R.P.); (S.J.)
| | - Sofia Jadavji
- Aga Khan Foundation, Ottawa, ON K1N 1K6, Canada; (L.M.); (R.P.); (S.J.)
| | - Jerim Obure
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi P.O. Box 30270-00100, Kenya; (V.N.); (S.W.); (J.O.); (M.T.)
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi P.O. Box 30270-00100, Kenya; (V.N.); (S.W.); (J.O.); (M.T.)
| |
Collapse
|
13
|
Apolot RR, Ekirapa E, Waldman L, Morgan R, Aanyu C, Mutebi A, Nyachwo EB, Seruwagi G, Kiwanuka SN. Maternal and newborn health needs for women with walking disabilities; "the twists and turns": a case study in Kibuku District Uganda. Int J Equity Health 2019; 18:43. [PMID: 30866957 PMCID: PMC6416885 DOI: 10.1186/s12939-019-0947-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 03/05/2019] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND In Uganda 13% of persons have at least one form of disability. The United Nations' Convention on the Rights of Persons with Disabilities guarantees persons with disabilities the same level of right to access quality and affordable healthcare as persons without disability. Understanding the needs of women with walking disabilities is key in formulating flexible, acceptable and responsive health systems to their needs and hence to improve their access to care. This study therefore explores the maternal and newborn health (MNH)-related needs of women with walking disabilities in Kibuku District Uganda. METHODS We carried out a qualitative study in September 2017 in three sub-counties of Kibuku district. Four In-depth Interviews (IDIs) among purposively selected women who had walking disabilities and who had given birth within two years from the study date were conducted. Trained research assistants used a pretested IDI guide translated into the local language to collect data. All IDIs were audio recorded and transcribed verbatim before analysis. The thematic areas explored during analysis included psychosocial, mobility, health facility and personal needs of women with walking disabilities. Data was analyzed manually using framework analysis. RESULTS We found that women with walking disabilities had psychosocial, mobility, special services and personal needs. Psychosocial needs included; partners', communities', families' and health workers' acceptance. Mobility needs were associated with transport unsuitability, difficulty in finding transport and high cost of transport. Health facility needs included; infrastructure, and responsive health services needs while personal MNH needs were; personal protective wear, basic needs and birth preparedness items. CONCLUSIONS Women with walking disabilities have needs addressable by their communities and the health system. Communities, and health workers need to be sensitized on these needs and policies to meet and implement health system-related needs of women with disability.
Collapse
Affiliation(s)
- Rebecca R. Apolot
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O.Box 7072, Kampala, Uganda
| | - Elizabeth Ekirapa
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O.Box 7072, Kampala, Uganda
| | - Linda Waldman
- Institute of Development Studies, Library Road, Brighton, BN1 9RE UK
| | - Rosemary Morgan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - Christine Aanyu
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O.Box 7072, Kampala, Uganda
| | - Aloysius Mutebi
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O.Box 7072, Kampala, Uganda
| | - Evelyne B. Nyachwo
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O.Box 7072, Kampala, Uganda
| | - Gloria Seruwagi
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O.Box 7072, Kampala, Uganda
| | - Suzanne N. Kiwanuka
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O.Box 7072, Kampala, Uganda
| |
Collapse
|
14
|
Zuurmond M, O’Banion D, Gladstone M, Carsamar S, Kerac M, Baltussen M, Tann CJ, Gyamah Nyante G, Polack S. Evaluating the impact of a community-based parent training programme for children with cerebral palsy in Ghana. PLoS One 2018; 13:e0202096. [PMID: 30180171 PMCID: PMC6122808 DOI: 10.1371/journal.pone.0202096] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 07/22/2018] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND In low and middle-income settings, where access to support and rehabilitation services for children with disabilities are often lacking, the evidence base for community initiatives is limited. This study aimed to explore the impact of a community-based training programme for caregivers of children with cerebral palsy in Ghana. METHODS A pre and post evaluation of an 11-month participatory training programme ("Getting to Know Cerebral Palsy") offered through a parent group model, was conducted. Eight community groups, consisting of a total of 75 caregivers and their children with cerebral palsy (aged 18 months-12 years), were enrolled from 8 districts across Ghana. Caregivers were interviewed at baseline, and again at 2 months after the completion of the programme, to assess: quality of life (PedsQL™ Family Impact Module); knowledge about their child's condition; child health indicators; feeding practices. Severity of cerebral palsy, reported illness, and anthropometric measurements were also assessed. RESULTS Of the child-caregiver pairs, 64 (84%) were included in final analysis. There were significant improvements in caregiver quality of life score (QoL) (median total QoL 12.5 at baseline to 51.4 at endline, P<0.001). Caregivers reported significant improvements in knowledge and confidence in caring for their child (p<0.001), in some aspects of child feeding practices (p<0.001) and in their child's physical and emotional heath (p< 0.001). Actual frequency of reported serious illness over 12-months remained high (67%) among children, however, a small reduction in recent illness episodes (past 2 weeks) was seen (64% to 50% p < 0.05). Malnutrition was common at both time points; 63% and 65% of children were classified as underweight at baseline and endline respectively (p = 0.5). CONCLUSION Children with cerebral palsy have complex care and support needs which in low and middle-income settings need to be met by their family. This study demonstrates that a participatory training, delivered through the establishment of a local support group, with an emphasis on caregiver empowerment, resulted in improved caregiver QoL. Despite less effect on effect on child health and no clear effect on nutritional status, this alone is an important outcome. Whilst further development of these programmes would be helpful, and is underway, there is clear need for wider scale-up of an intervention which provides support to families.
Collapse
Affiliation(s)
- Maria Zuurmond
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David O’Banion
- School of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Melissa Gladstone
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Sandra Carsamar
- Physiotherapy Department, Korle Bu Teaching Hospital, Accra, Ghana
| | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Cally J. Tann
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Sarah Polack
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
15
|
Polack S, Adams M, O'banion D, Baltussen M, Asante S, Kerac M, Gladstone M, Zuurmond M. Children with cerebral palsy in Ghana: malnutrition, feeding challenges, and caregiver quality of life. Dev Med Child Neurol 2018; 60:914-921. [PMID: 29736993 DOI: 10.1111/dmcn.13797] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2018] [Indexed: 12/21/2022]
Abstract
AIM To assess feeding difficulties and nutritional status among children with cerebral palsy (CP) in Ghana, and whether severity of feeding difficulties and malnutrition are independently associated with caregiver quality of life (QoL). METHOD This cross-sectional survey included 76 children with CP (18mo-12y) from four regions of Ghana. Severity of CP was classified using the Gross Motor Function Classification System and anthropometric measures were taken. Caregivers rated their QoL (using the Pediatric Quality of Life Inventory Family Impact Module) and difficulties with eight aspects of child feeding. Logistic regression analysis explored factors (socio-economic characteristics, severity of CP, and feeding difficulties) associated with being underweight. Linear regression was undertaken to assess the relationship between caregiver QoL and child malnutrition and feeding difficulties. RESULTS Poor nutritional status was common: 65% of children aged under 5 years were categorized as underweight, 54% as stunted, and 58% as wasted. Reported difficulties with child's feeding were common and were associated with the child being underweight (odds ratio 10.7, 95% confidence interval 2.3-49.6) and poorer caregiver QoL (p<0.001). No association between caregiver QoL and nutritional status was evident. INTERPRETATION Among rural, low resource populations in Ghana, there is a need for appropriate, accessible caregiver training and support around feeding practices of children with CP, to improve child nutritional status and caregiver well-being. WHAT THIS PAPER ADDS Malnutrition is very common among children with cerebral palsy in this rural population in Ghana. Feeding difficulties in this population were strongly associated with being underweight. Feeding difficulties were associated with poorer caregiver quality of life (QoL). Child nutritional status was not associated with caregiver QoL.
Collapse
Affiliation(s)
- Sarah Polack
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Mel Adams
- Independent Consultant in Disability and International Development, London, UK
| | - David O'banion
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Sandra Asante
- Physiotherapy Department, Korle Bu Teaching Hospital, Accra, Ghana
| | - Marko Kerac
- Department of Population Health, Faculty of Epidemiology and Public Health, London School of Hygiene & Tropical Medicine, London, UK.,Leonard Cheshire Disability and Inclusive Development Centre, Department of Epidemiology and Child Health, University College London, London, UK
| | - Melissa Gladstone
- Department of Women and Children's Health Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Maria Zuurmond
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
16
|
Quarmby CA, Pillay M. The intersection of disability and food security: Perspectives of health and humanitarian aid workers. Afr J Disabil 2018; 7:322. [PMID: 38362205 PMCID: PMC10867669 DOI: 10.4102/ajod.v7i0.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 11/03/2017] [Indexed: 02/17/2024] Open
Abstract
Background Most people with disabilities the world over can be found in the Majority (or 'economically developing') World. This is also where most of the world's hungry and malnourished are found. We argue that the intersectionality between disability and nutrition may best be understood through a food security framework, and we position all people living with disability, including those experiencing feeding and swallowing disabilities, as at risk for food insecurity, especially those living in humanitarian emergency contexts. Objectives This study aimed to explore and describe the knowledge and experience of humanitarian aid workers (HAWs) and health care professionals (HCPs) in food assistance contexts with regard to the nutrition and food security of people living with disabilities. Method In this exploratory, descriptive study, 16 participants with experience in sub-Saharan Africa and Southern Asia participated in an online survey. Three survey participants with extensive experience were also interviewed. Data analysis involved descriptive statistics and thematic content analysis. Results Results revealed that participants had generally low levels of exposure to and experience with disability, including swallowing and feeding disorders. Conclusions Reduced knowledge of HAWs and HCPs regarding disability and the lack of professionals such as speech-language therapists, who manage disability-specific issues such as feeding and swallowing disorders, may affect the food security of people living with disabilities in food assistance contexts.
Collapse
Affiliation(s)
- Candice A Quarmby
- Disciplines of Audiology & Speech-Language Therapy, University of KwaZulu-Natal, South Africa
| | - Mershen Pillay
- Discipline of Speech-Language Pathology, University of KwaZulu-Natal, South Africa
| |
Collapse
|
17
|
Abstract
The main forms of childhood malnutrition occur predominantly in children <5 years of age living in low-income and middle-income countries and include stunting, wasting and kwashiorkor, of which severe wasting and kwashiorkor are commonly referred to as severe acute malnutrition. Here, we use the term 'severe malnutrition' to describe these conditions to better reflect the contributions of chronic poverty, poor living conditions with pervasive deficits in sanitation and hygiene, a high prevalence of infectious diseases and environmental insults, food insecurity, poor maternal and fetal nutritional status and suboptimal nutritional intake in infancy and early childhood. Children with severe malnutrition have an increased risk of serious illness and death, primarily from acute infectious diseases. International growth standards are used for the diagnosis of severe malnutrition and provide therapeutic end points. The early detection of severe wasting and kwashiorkor and outpatient therapy for these conditions using ready-to-use therapeutic foods form the cornerstone of modern therapy, and only a small percentage of children require inpatient care. However, the normalization of physiological and metabolic functions in children with malnutrition is challenging, and children remain at high risk of relapse and death. Further research is urgently needed to improve our understanding of the pathophysiology of severe malnutrition, especially the mechanisms causing kwashiorkor, and to develop new interventions for prevention and treatment.
Collapse
Affiliation(s)
- Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research &Learning, 686 Bay Street, Toronto, Ontario, M5G 0A4, Canada
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - James A Berkley
- Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness &Nutrition (CHAIN) Network, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Robert H J Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research &Learning, 686 Bay Street, Toronto, Ontario, M5G 0A4, Canada
- The Childhood Acute Illness &Nutrition (CHAIN) Network, Nairobi, Kenya
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Marko Kerac
- Department of Population Health, London School of Hygiene &Tropical Medicine, London, UK
| | - Indi Trehan
- Lao Friends Hospital for Children, Luang Prabang, Laos
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi
| | - André Briend
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
18
|
Zuurmond M, Nyapera V, Mwenda V, Kisia J, Rono H, Palmer J. Childhood disability in Turkana, Kenya: Understanding how carers cope in a complex humanitarian setting. Afr J Disabil 2016; 5:277. [PMID: 28730061 PMCID: PMC5433466 DOI: 10.4102/ajod.v5i1.277] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 07/01/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Although the consequences of disability are magnified in humanitarian contexts, research into the difficulties of caring for children with a disability in such settings has received limited attention. METHODS Based on in-depth interviews with 31 families, key informants and focus group discussions in Turkana, Kenya, this article explores the lives of families caring for children with a range of impairments (hearing, vision, physical and intellectual) in a complex humanitarian context characterised by drought, flooding, armed conflict, poverty and historical marginalisation. RESULTS The challenging environmental and social conditions of Turkana magnified not only the impact of impairment on children, but also the burden of caregiving. The remoteness of Turkana, along with the paucity and fragmentation of health, rehabilitation and social services, posed major challenges and created opportunity costs for families. Disability-related stigma isolated mothers of children with disabilities, especially, increasing their burden of care and further limiting their access to services and humanitarian programmes. In a context where social systems are already stressed, the combination of these factors compounded the vulnerabilities faced by children with disabilities and their families. CONCLUSION The needs of children with disabilities and their carers in Turkana are not being met by either community social support systems or humanitarian aid programmes. There is an urgent need to mainstream disability into Turkana services and programmes.
Collapse
Affiliation(s)
- Maria Zuurmond
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | | | | | | | - Hilary Rono
- London School of Hygiene and Tropical Medicine, and Opthalmologist, Kitale, Kenya
| | - Jennifer Palmer
- Department of Infectious Diseases Epidemiology, London School of Hygiene & Tropical Medicine, UK
- Centre of African Studies, School of Political & Social Sciences, University of Edinburgh, London, UK
| |
Collapse
|
19
|
Hanass-Hancock J, Myezwa H, Carpenter B. Disability and Living with HIV: Baseline from a Cohort of People on Long Term ART in South Africa. PLoS One 2015; 10:e0143936. [PMID: 26625001 PMCID: PMC4666651 DOI: 10.1371/journal.pone.0143936] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 11/11/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Through access to life saving antiretroviral treatment (ART) in southern Africa, HIV has been reconceptualised as a chronic disease. This comes with new challenges of HIV-related co-morbidities and disabilities. We still lack an understanding of the types and scope of disabilities experienced by people on long term ART and how this impacts health, adherence, and livelihood. This paper describes the results of a cohort study examining the new health- and disability-related needs of the millions of people on ART in the region. METHODS Data was collected from a cohort of people who had been on ART for six months or longer in a semi-urban public health care setting in South Africa. 1042 adults (18 and older) participated in the cross-sectional study which investigated disabilities/activity limitations, health, ART adherence, depression symptoms, and livelihood. We analysed the associations between these constructs using descriptive statistics, and bivariate and multivariate analyses. RESULTS A large number of participants (35.5%) obtained a weighted score of two or more on the WHODAS 2.0 indicating possible activity limitations. A positive relationship was found between activity limitations and depression symptoms, adherence, and worse health outcomes, while none was found for BMI or CD4 count. These associations varied by type of activity limitations and, in some cases, by gender. CONCLUSION Activity limitations are potentially experienced by a large portion of people on ART in southern Africa which impacts health and ART adherence negatively. These results highlight the importance of better understanding the new health-related needs of people who are on long term ART, as well as the nuances of the disability they experience. This is urgently needed in order to enable HIV-endemic countries to better prepare for the new health-related needs of the millions of people on ART in southern Africa.
Collapse
Affiliation(s)
- Jill Hanass-Hancock
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Hellen Myezwa
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Bradley Carpenter
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| |
Collapse
|
20
|
Groce N, Challenger E, Berman-Bieler R, Farkas A, Yilmaz N, Schultink W, Clark D, Kaplan C, Kerac M. Malnutrition and disability: unexplored opportunities for collaboration. Paediatr Int Child Health 2014; 34:308-14. [PMID: 25309998 PMCID: PMC4232244 DOI: 10.1179/2046905514y.0000000156] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
There is increasing international interest in the links between malnutrition and disability: both are major global public health problems, both are key human rights concerns, and both are currently prominent within the global health agenda. In this review, interactions between the two fields are explored and it is argued that strengthening links would lead to important mutual benefits and synergies. At numerous points throughout the life-cycle, malnutrition can cause or contribute to an individual's physical, sensory, intellectual or mental health disability. By working more closely together, these problems can be transformed into opportunities: nutrition services and programmes for children and adults can act as entry points to address and, in some cases, avoid or mitigate disability; disability programmes can improve nutrition for the children and adults they serve. For this to happen, however, political commitment and resources are needed, as are better data.
Collapse
Affiliation(s)
- N Groce
- Leonard Cheshire Disability and Inclusive Development Centre, University College London, UK
| | - E Challenger
- Leonard Cheshire Disability and Inclusive Development Centre, University College London, UK
| | | | | | | | | | | | - C Kaplan
- Spoon Foundation, Portland, Oregon, USA
| | - M Kerac
- Leonard Cheshire Disability and Inclusive Development Centre, University College London, UK
| |
Collapse
|
21
|
An R, Chiu CY, Zhang Z, Burd NA. Nutrient intake among US adults with disabilities. J Hum Nutr Diet 2014; 28:465-75. [PMID: 25233949 DOI: 10.1111/jhn.12274] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Physical, mental and financial barriers among persons with disabilities limit their access to healthier diet. The present study investigated the relationship between disabilities and nutrient intake among US adults. METHODS Data originated from National Health and Nutrition Examination Survey 2007-2008 and 2009-2010 waves (n = 11,811). Five disability categories include activities of daily living (ADLs), instrumental activities of daily living (IADLs), leisure and social activities (LSAs), lower extremity mobility (LEM) and general physical activities (GPAs). Nutrient intakes from food and dietary supplements were calculated from 24-h dietary recalls. Adherence to dietary reference intakes and dietary guideline recommendations was compared between people with and without disabilities and across disability categories in the statistical analysis. RESULTS GPAs, IADLs, LSAs, LEM and ADLs occupied 24.5%, 13.3%, 9.9%, 9.2% and 9.2% of US adults, respectively (not mutually exclusive). Only 42.3%, 11.3%, 63.8%, 47.7%, 48.7%, 9.7%, 48.7%, 90.7%, 21.7% and 4.7% of adults had saturated fat, fibre, cholesterol, vitamin A, vitamin C, vitamin D, calcium, iron, sodium and potassium intakes from food within recommended levels, respectively. Dietary supplement use moderately improved vitamin C, vitamin D and calcium intakes. People with disabilities were less likely to meet recommended levels on saturated fat, fibre (except GPAs), vitamin A (except GPAs), vitamin C (except GPAs), calcium and potassium intakes than persons without disability. Nutrient intake differed across disability categories, with ADLs least likely to meet recommended intakes. CONCLUSIONS Interventions targeting persons with disabilities through nutrition education and financial assistance are warranted to promote healthy diet and reduce disparities.
Collapse
Affiliation(s)
- R An
- Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| | - C Y Chiu
- Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| | - Z Zhang
- Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| | - N A Burd
- Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| |
Collapse
|
22
|
The impact of disability on the lives of children; cross-sectional data including 8,900 children with disabilities and 898,834 children without disabilities across 30 countries. PLoS One 2014; 9:e107300. [PMID: 25202999 PMCID: PMC4159292 DOI: 10.1371/journal.pone.0107300] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 08/11/2014] [Indexed: 11/29/2022] Open
Abstract
Background Children with disabilities are widely believed to be less likely to attend school or access health care, and more vulnerable to poverty. There is currently little large-scale or internationally comparable evidence to support these claims. The aim of this study was to investigate the impact of disability on the lives of children sponsored by Plan International across 30 countries. Methods and Findings We conducted a cross-sectional survey including 907,734 children aged 0–17 participating in the Plan International Sponsorship Programme across 30 countries in 2012. Parents/guardians were interviewed using standardised questionnaires including information on: age, sex, health, education, poverty, and water and sanitation facilities. Disability was assessed through a single question and information was collected on type of impairment. The dataset included 8,900 children with reported disabilities across 30 countries. The prevalence of disability ranged from 0.4%–3.0% and was higher in boys than girls in 22 of the 30 countries assessed – generally in the range of 1.3–1.4 fold higher. Children with disabilities were much less likely to attend formal education in comparison to children without disabilities in each of the 30 countries, with age-sex adjusted odds ratios exceeding 10 for nearly half of the countries. This relationship varied by impairment type. Among those attending school, children with disabilities were at a lower level of schooling for their age compared to children without disabilities. Children with disabilities were more likely to report experiencing a serious illness in the last 12 months, except in Niger. There was no clear relationship between disability and poverty. Conclusions Children with disabilities are at risk of not fulfilling their educational potential and are more vulnerable to serious illness. This exclusion is likely to have a long-term deleterious impact on their lives unless services are adapted to promote their inclusion.
Collapse
|
23
|
Nutrient intake and use of dietary supplements among US adults with disabilities. Disabil Health J 2014; 8:240-9. [PMID: 25306424 DOI: 10.1016/j.dhjo.2014.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 08/03/2014] [Accepted: 09/02/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND Physical, mental, social, and financial hurdles in adults with disabilities may limit their access to adequate nutrition. OBJECTIVE To examine the impact of dietary supplement use on daily total nutrient intake levels among US adults 20 years and older with disabilities. METHODS Study sample came from 2007-2008 and 2009-2010 waves of the National Health and Nutrition Examination Survey, a nationally representative repeated cross-sectional survey. Disability was classified into 5 categories using standardized indices. Nutrient intakes from foods and dietary supplements were calculated from 2 nonconsecutive 24-hour dietary recalls. Two-sample proportion tests and multiple logistic regressions were used to examine the adherence rates to the recommended daily nutrient intake levels between dietary supplement users and nonusers in each disability category. The association between sociodemographic characteristics and dietary supplement use was assessed using multiple logistic regressions, accounting for complex survey design. RESULTS A substantial proportion of the US adult population with disabilities failed to meet dietary guidelines, with insufficient intakes of multiple nutrients. Over half of the US adults with disabilities used dietary supplements. Dietary supplement use was associated with higher adherence rates for vitamin A, vitamin B1, vitamin B2, vitamin B6, vitamin B12, vitamin C, vitamin D, vitamin E, calcium, copper, iron, magnesium, and zinc intake among adults with disabilities. Women, non-Hispanic Whites, older age, higher education, and higher household income were found to predict dietary supplement use. CONCLUSIONS Proper use of dietary supplements under the guidance of health care providers may improve the nutritional status among adults with disabilities.
Collapse
|
24
|
Follow-up of post-discharge growth and mortality after treatment for severe acute malnutrition (FuSAM study): a prospective cohort study. PLoS One 2014; 9:e96030. [PMID: 24892281 PMCID: PMC4043484 DOI: 10.1371/journal.pone.0096030] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 04/03/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Management of Severe Acute Malnutrition (SAM) plays a vital role in achieving global child survival targets. Effective treatment programmes are available but little is known about longer term outcomes following programme discharge. METHODS From July 2006 to March 2007, 1024 children (median age 21.5 months, IQR 15-32) contributed 1187 admission episodes to an inpatient-based SAM treatment centre in Blantyre, Malawi. Long term outcomes, were determined in a longitudinal cohort study, a year or more after initial programme discharge. We found information on 88%(899/1024). RESULTS In total, 42%(427/1024) children died during or after treatment. 25%(105/427) of deaths occurred after normal programme discharge, >90 days after admission. Mortality was greatest among HIV seropositive children: 62%(274/445). Other risk factors included age <12 months; severity of malnutrition at admission; and disability. In survivors, weight-for-height and weight-for-age improved but height-for-age remained low, mean -2.97 z-scores (SD 1.3). CONCLUSIONS Although SAM mortality in this setting was unacceptably high, our findings offer important lessons for future programming, policy and research. First is the need for improved programme evaluation: most routine reporting systems would have missed late deaths and underestimated total mortality due to SAM. Second, a more holistic view of SAM is needed: while treatment will always focus on nutritional interventions, it is vital to also identify and manage underlying clinical conditions such as HIV and disability. Finally early identification and treatment of SAM should be emphasised: our results suggest that this could improve longer term as well as short term outcomes. As international policy and programming becomes increasingly focused on stunting and post-malnutrition chronic disease outcomes, SAM should not be forgotten. Proactive prevention and treatment services are essential, not only to reduce mortality in the short term but also because they have potential to impact on longer term morbidity, growth and development of survivors.
Collapse
|
25
|
Kerac M, Postels DG, Mallewa M, Alusine Jalloh A, Voskuijl WP, Groce N, Gladstone M, Molyneux E. The interaction of malnutrition and neurologic disability in Africa. Semin Pediatr Neurol 2014; 21:42-9. [PMID: 24655404 DOI: 10.1016/j.spen.2014.01.003] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Malnutrition and neurodisability are both major public health problems in Africa. This review highlights key areas where they interact. This happens throughout life and starts with maternal malnutrition affecting fetal neurodevelopment with both immediate (eg, folate deficiency causing neural tube defects) and lifelong implications (eg, impaired cognitive function). Maternal malnutrition can also increase the risk of perinatal problems, including birth asphyxia, a major cause of neurologic damage and cerebral palsy. Macronutrient malnutrition can both cause and be caused by neurodisability. Mechanisms include decreased food intake, increased nutrient losses, and increased nutrient requirement. Specific micronutrient deficiencies can also lead to neurodisability, for example, blindness (vitamin A), intractable epilepsy (vitamin B6), and cognitive impairment (iodine and iron). Toxin ingestion (eg, from poorly processed cassava) can cause neurodisability including a peripheral polyneuropathy and a spastic paraparesis. We conclude that there is an urgent need for nutrition and disability programs to work more closely together.
Collapse
Affiliation(s)
- Marko Kerac
- Leonard Cheshire Disability and Inclusive Development Centre, University College London, UK; Malawi-Liverpool Wellcome Trust Clinical Research Programme, Malawi
| | - Douglas G Postels
- International Neurologic and Psychiatric Epidemiology Program, Michigan State University, MI
| | - Mac Mallewa
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Malawi; Department of Paediatrics and Child Health, College of Medicine, Malawi
| | | | - Wieger P Voskuijl
- Leonard Cheshire Disability and Inclusive Development Centre, University College London, UK
| | - Nora Groce
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Malawi
| | | | - Elizabeth Molyneux
- Department of Paediatrics and Child Health, College of Medicine, Malawi.
| |
Collapse
|